Why helping countries deliver COVID-19 vaccines is just as vital as boosting supply

Getting COVID-19 vaccines out to countries isn’t just about ensuring supply – a major stumbling block can be their ‘absorptive capacity,’ or the ability to deliver the volume of vaccine coming their way. Here, we talk to Alex de Jonquieres, Director of Health Systems & Immunisation Strengthening at Gavi, about supporting countries in delivering their doses.

  • 3 September 2021
  • 8 min read
  • by Priya Joi
Lunana's first female health worker with the vaccine carrier that was flown into Lhedi village to conduct the second dose of COVID-19 vaccination. Photo: UNICEF Bhutan/2021/Namgay Dorji
Lunana's first female health worker with the vaccine carrier that was flown into Lhedi village to conduct the second dose of COVID-19 vaccination. Photo: UNICEF Bhutan/2021/Namgay Dorji


Q. What are the challenges countries face today in preparing to scale up COVID-19 vaccination?

A. Every country already has a system that is delivering routine immunisation and other health services on a regular basis. But with the sheer volume of COVID-19 vaccines, countries are going to be dealing with about five times the volume of vaccines that they normally would. They're also going be delivering vaccines to parts of the population they don’t normally have to target. Typically, immunisations are delivered to infants or adolescents, but many countries do not have an adult vaccination programme.

Efforts to expand the cold chain, build confidence in vaccines and identify and engage missed populations will continue to benefit health systems for years to come.

Also, while most countries have rolled out mass vaccination campaigns before, they tend to start planning these a year or two in advance, with predictability around vaccine supply. Whereas with COVID-19 vaccines, we're talking supply that is coming from multiple sources, while the timing of delivery is often unpredictable. This is especially true of donated doses, which are often being made available in small quantities at very short notice. And on top of that, the health systems in charge of rolling out the vaccine are already very stretched in responding to the pandemic that is still ongoing.

Q. What about gaps in absorptive capacity such as cold chain challenges?

A. Cold chain is definitely one of the bottlenecks. But Gavi has invested a huge amount into cold chain over the years, especially through the Cold Chain Equipment Optimization Platform (CCEOP). We’ve procured about 65,000 units of cold chain equipment since 2017 alone; most of that capacity has gone into health facilities, so that's much stronger than it was before. We are also providing additional support for the COVID-19 response to strengthen higher levels of the cold chain, and are aiming to ensure all countries can store enough COVID-19 vaccine for at least 10% of their population at any time, in addition to the full complement of routine vaccines. We are moving very quickly to deploy ultra-cold chain equipment , which does not exist in most countries’ immunisation supply chains, so that countries are in a position to deploy the large volumes of Pfizer vaccine we expect to supply through COVAX over the coming months.

But there are many other issues that are important to focus on. For example, if countries are dealing with more than five times the normal volume of vaccines, that means health workers are going to have to deliver five times as many jabs. In some cases, countries have brought in retired health staff or medical students to expand their health workforce’s capacity, or set up mass vaccination sites to enable each health worker to vaccinate more people per hour. So that's the kind of adaptation that will be needed to ensure service delivery capacity, while also continuing to provide other essential health services. 

We’ve also seen challenges with vaccine hesitancy. This has not been a big issue historically for immunisation in most Gavi-supported countries, but it has been a significant challenge in some countries for COVID vaccines, often fed by misinformation and rumours. There have been instances where even health workers have been hesitant to be immunised themselves, despite being at greatest risk. There’s also been a challenge that vaccine hesitancy that can be product-specific. For example, people might say they don’t want a particular brand of vaccine. 

These challenges will evolve as countries reach a higher share of their population. For example, as countries scale up vaccination, they will both have to get their service delivery infrastructure reaching parts of the population that are harder to reach, which costs more in terms of capacity and time. Similarly, they will increasingly be seeking to reach populations that may be more hesitant. So countries will need to adapt their strategies as they scale up.

Q. What is Gavi doing to support countries in vaccine delivery?

Last year, we had already identified technical assistance and cold chain as key areas where Gavi would support countries, with the Board approving $150M of support in September. Technical assistance was needed early to help countries to plan, and we’ve supported the deployment of over 450 WHO and UNICEF staff to support countries. And we knew that deployment of cold chain has long lead times, which is why we provided support for that early on.

Over time, there was growing concern over gaps in delivery funding. Donors contributed US$772 million for COVAX to support COVID vaccine delivery and we've broken it down into a few streams. The biggest area is flexible support for countries as they have different capacity and needs. About US$270 million is rapidly available funds for all countries with very light application process, that we aim to approve within days of receipt. After this, if countries still have critical needs, there is a further fund they can apply to. 

We have also allocated additional funding for areas which we believe need targeted support. This includes rapid deployment and installation of ultra cold chain capacity in-country, helping countries to strengthen stock management and manage the massive throughput of doses in their supply chains, and building vaccine confidence including by countering misinformation and rumours – all of which is being led by our Alliance partner UNICEF. We also have dedicated support to provide management surge capacity, helping to embed additional capacity into overstretched Ministry of Health teams. 

And there are other cross-cutting investments that we are making. One is trying to rapidly identify and help prepare for scale innovations – such as GIS (Geographic Information System) mapping to help countries plan delivery based on satellite imagery, or digital tracking of rumors and misinformation to be able to rapidly tackle them. We’re also providing funding for delivery of doses made available through the humanitarian buffer that will ensure access to COVID-19 vaccines for high-risk populations in humanitarian settings.

Q. It will be a challenge for countries to manage supply as well as ramp up their capacity to deliver COVID-19 vaccines. But will this bring sustainable benefits for the future?

There are at least four ways in which countries’ COVID-19 vaccination programmes could leave a long-term legacy. Firstly, there has never been such an intense political focus on the importance of immunisation and ensuring equitable access to healthcare. COVID-19 has demonstrated the health, political, economic and moral cases for ensuring we reach everyone with effective health care services. Hopefully, we can sustain this emphasis on ensuring equitable access to all essential health services well beyond the pandemic.

Secondly, countries are investing significantly in expanding their immunisation programme and health systems capacity. Efforts to expand the cold chain, build confidence in vaccines and identify and engage missed populations will continue to benefit health systems for years to come.

Moreover, in setting up COVID vaccination programmes, countries are building a platform to deliver adult vaccines going forward. Countries are building the capacity to identify and reach adult populations with vaccines and, if, as is looking increasingly likely, countries will need to re-immunise parts of populations because of new variants, or waning immunity and so on, that means countries will need immunisation programmes that can continually reach at least a portion of the adult population. That can serve as a platform for delivery of other vaccines that are delivered to non-infant age groups, both existing ones (e.g. influenza) and potential future ones (E.g., TB or malaria).

Lastly, necessity is the mother of invention and we are seeing a huge pace of innovation in countries’ responses to COVID-19. This is also helping to catalyse new ways of working and rapid scale up of new technologies that might otherwise have taken years. Hopefully, these innovations will be mainstreamed into regular programmes and help drive transformations such as the digitisation of supply chains, which can have significant impact for years to come. 

Q. Are there good examples of how countries have improved their absorptive capacity?

Yes several countries have made great strides in boosting their absorptive capacity. Pakistan, for instance, is delivering 1 million doses a day of different vaccines. They have strong federal and provincial political and financial commitment, and the country has built upon its immunisation and polio program infrastructure to roll out COVID vaccines nationwide, with an emphasis on mass vaccination centres in urban sites. Pakistan is also developing other strategies to ensure that Pakistanis without government ID, rural populations, women, refugees and migrants have access to vaccines, which is critical for vaccine equity. 

Angola is another good example of using different strategies to boost delivery. The country has ensured cross-sectoral mobilisation at the government, private sector and local association levels and made early investments in the purchase of ultra-cold chain equipment. They have also set up electronic registry for COVID-19 immunisation backed by an existing electronic logistics management information system. Finally, Angola has set up high-performance vaccination centres, building on the experience of the approaches used during the yellow fever epidemic in 2016.

These are just two examples of the leadership and innovation we are seeing from many countries that COVAX is supporting in scaling up COVID vaccination.